Chronic Anterior Knee Research Articles

Beyond the patella: Treatment of cam femoroacetabular impingement syndrome improves anterior knee pain

ObjectivesThis study aimed to investigate if there is a relationship between cam femoroacetabular impingement syndrome (cam-FAIS) and chronic anterior knee pain (AKP). MethodsThis is a pilot retrospective review of 12 AKP patients with no structural anomalies in the patellofemoral joint and no skeletal malalignment in the lower limbs. All the patients were resistant to proper conservative treatment for AKP (AKP-R). Subsequently, these patients developed pain in the ipsilateral hip several months later, and upon evaluation, were diagnosed with cam-FAIS. Arthroscopic femoral osteoplasty and labral repair were performed and clinical follow-up of hip and knee pain and function (Kujala Score and Non-arthritic Hip Score -NAHS-) was carried out. ResultsAll the patients showed improvement in the knee and hip pain scores with a statistically significant clinical difference in all of them at 69 months follow up (range: 18 to 115) except one patient without improvement in the groin VAS score post-operatively. Visual analogical scale (VAS) of knee pain improved from 6.3 (range: 5 to 8) to a postoperative 0.5 (range: 0 to 3.5), (p ​< ​0.001). The VAS of groin pain improved from 4.4 (range: 2 to 8) to a postoperative 0.9 (range: 0 to 3), (p ​< ​0.001). NAHS improved from a preoperative 67.9 (range: 28.7 to 100) to a postoperative 88 (range: 70 to 100), (p ​< ​0.015) and knee Kujala's score improved from a preoperative 48.7 (range: 22 to 71) to a postoperative 96 (range: 91 to 100), (p ​< ​0.001). ConclusionThis study's principal finding suggests an association between cam-FAIS and AKP-R in young patients who exhibit normal knee imaging and lower limbs skeletal alignment. Addressing cam-FAIS in these cases leads to resolution of both groin and knee pain, resulting in improved functional outcomes for both joints. Study designRetrospective cohort series with a single contemporaneous long-term follow-up. Level of EvidenceIV.

Patellar Tendon-Lateral Femoral Condyle Friction Syndrome: About 5 Cases

Objective: The objective is to illustrate the MR imaging findings occurring in the posterior inferolateral patellar tendon and the lateral femoral condyle in patients experiencing chronic anterior and/or lateral knee pain. Material and methods: A retrospective review of the MR images in (patients who presented with chronic anterior or lateral knee pain. In all patients, postcontrast images were available. Results: Sagittal and axial imaging planes best demonstrated the patellar tendon and its relationship with the lateral femoral condyle. In all the patients, there was obliteration of the fat planes and abnormal signal intensity in the lateral soft tissues of the inferior patellofemoral joint. Enhancement after administration of gadolinium was noted in all cases in which contrast was administered. One patient showed cystic changes in the soft tissues adjacent to the lateral femoral condyle in addition to fat plane obliteration. Abnormal patellar alignment was noted in one patient. Patellar tendon pathology was seen in one patient. Conclusion: When assessing anterior knee symptoms, MR imaging facilitates the identification of changes associated with patellar tendon-lateral femoral condyle friction syndrome, which should be differentiated from other causes of anterior or lateral knee pain.

Chronic knee pain following infrapatellar/suprapatellar magnetic intramedullary lengthening nails versus external fixators in limb length discrepancy: A retrospective review

Aims & objectivesPrior to the popularization of magnetic intramedullary nails (MILNs), gradual deformity correction using external fixation was the norm in limb lengthening. Trauma literature has shown MILN via a suprapatellar approach (SP) to be associated with less knee pain than either an infrapatellar entry (IP) or external fixation. Yet, no research has investigated chronic knee pain and MILNs. We assessed differences in chronic knee pain following lengthening via an IP or SP approach with an MILN versus external fixation. Materials & methodsWe reviewed 147 limbs (55 MILN/IP, 22 MILN/SP, 71 external fixator) in 124 patients who underwent tibial lengthening with ≥12 months follow-up between February 2012 and July 2020. Knee pain was assessed pre- and postoperatively at 6 and 12 months, with the Lysholm Knee Scoring Scale (LKSS) and numeric pain scale (0-10). Differences in knee pain outcomes were compared across methods, with subgroup analysis of MILN/SP and MILN/IP. ResultsMean LKSS was 96.3 for external fixation and 88.5 for MILN (P = .011). In the MILN subgroups, mean LKSS was 91.7 for IP and 85.3 for SP. The IP group reported a lesser mean pain score (0.6 versus 2.1) at 12 months. Bilateral nail recipients demonstrated no knee pain differences versus unilateral. At 12 months postoperative, external fixation had better knee outcomes. ConclusionTibial lengthening with external fixation was associated with less chronic anterior knee pain and better functional outcomes than MILN overall. In terms of MILN approach, IP surpassed SP on subjective pain scores. Larger tibial lengthening and knee pain studies are warranted.

Chronic Anterior Knee Pain In A Naval Officer

Chronic Anterior Knee Pain In A Naval Officer

Diagnosis and treatment of patellofemoral joint arthritis

Background: Although patellofemoral arthritis is a common and debilitating orthopedic disorder, its treatment varies and remains controversial. This review aims to provide an overview of the current understanding of the pathophysiology of patellofemoral arthritis, as well as its various diagnostic and treatment options.Current Concepts: The pathophysiology of patellofemoral arthritis includes lower limb malalignment, trochlear and/or patellar dysplasia, patellar instability, trauma, and obesity. The disorder is characterized by chronic anterior knee pain aggravated by flexion of the knee joint. A critical imaging study of the Merchant and lateral knee radiographs may show the progression of patellofemoral arthritis and dysplasia of the patellofemoral joints. Non-pharmacologic treatment options for patellofemoral arthritis include patient education, self-management, exercise, weight loss, taping, bracing, and orthotics. Pharmacologic agents (non-steroidal anti-inflammatory drugs, acetaminophen, oral narcotics, and duloxetine) and intra-articular injection therapies (glucocorticoids, hyaluronic acid, platelet-rich plasma, and other regenerative therapies) can be helpful for symptom relief in patients with patellofemoral arthritis. The surgical treatment can begin with lateral retinacular release to realign and decompress the patellofemoral joint. If failure in the improvement of symptoms is noted, a tibial tubercle osteotomy can be considered in young and active patients. While the early design and technique of patellofemoral arthroplasty were less than encouraging, more recent implant design and surgical techniques have demonstrated robust results.Discussion and Conclusion: Patellofemoral arthritis is a unique entity compared with tibiofemoral arthritis marked by distinct epidemiology, biomechanics, and risk factors and treatment options. It is essential to understand its pathophysiology and ensure proper treatment options.

Radiofrequency Ablation of the Infrapatellar Branch of the Saphenous Nerve for the Treatment of Chronic Anterior Inferomedial Knee Pain.

Genicular nerve radiofrequency ablation (GNRFA) is an effective treatment for chronic knee pain related to osteoarthritis. It is often utilized when conservative management has failed and patients wish to avoid arthroplasty, are poor surgical candidates due to comorbid medical conditions, or in those suffering from persistent pain after arthroplasty. The classic targets for GNRFA include the superior lateral genicular nerve, superior medial genicular nerve, and inferior medial genicular nerve but multiple anatomic studies have demonstrated additional sensory innervation to the knee. In this research article, we propose an image-guided technique that can safely target the infrapatellar branch of the saphenous nerve which also provides sensory innervation to the anterior capsule. The proposed technique includes variations for conventional bipolar radiofrequency ablation, cooled radiofrequency ablation, dual-tined bipolar radiofrequency ablation, and monopolar radiofrequency ablation using a long axis approach. The described technique is based on updated anatomic studies and takes into account safety concerns such as thermal risk to the skin and/or pes anserine tendons and breaching of the synovial cavity. Future clinical research should be performed to confirm the safety and effectiveness of this specific approach.

The Dynamic Effect of Anterior Cruciate Ligament Deficiency on Patellar Height.

The anterior tibial translation (ATT) in case of Anterior Cruciate Ligament (ACL) tear can lead to dynamic alterations of the extensor apparatus biomechanics. The aim of this study is to evaluate the dynamic effect of isolated ACL deficiency on patellar height. The hypothesis is that the ATT of ACL-insufficient knees dynamically reduces patellar height. Skeletally mature patients who underwent ACL reconstruction using hamstring graft between January and December 2018 were included in this study.The Posterior Tibial Slope (PTS), Caton-Deschamps (CDI), modified Insall-Salvati (MISI), and Blackburne-Peel (BPI) indices were calculated in standard lateral and TELOS X-rays. The mean of the measurements calculated between two observers was used to compare these parameters. 95 patients (M: 57; F: 38; 95 knees) were included in the study with a mean age of 31.8years (16-56years old). Significant patellar height reduction (CDI: 0.11 [-0.32; 0.31]; MISI: 0.09 [-0.66; 0.30]) was reported in TELOS compared with standard lateral knee radiography (p < 0.001). 20.0% of the study knees reported an abnormal CDI and 84.2% (16/19 knees) of them reduced this index to within normal limits in TELOS. 20.0% of the knees with mild patella alta reduced CDI in TELOS but always remained above 1.2. The abnormal ATT in case of ACL-deficient knees results in a lowering effect of the patella in TELOS X-rays. In patients with ACL tear and anterior pain the reconstructive ligament surgery should be performed to avoid also chronic anterior knee pain. Basic Science Study (Case Series). The decrease in patellar height in stress-X-rays compared with standard lateral knee radiography in ACL deficient knees, should be considered as a possible contributing cause of anterior pain in these patients.

Arthroscopic Resection of Symptomatic Tibial Tubercle Ossicles for Recalcitrant Osgood-Schlatter Disease Using a 2-Portal Technique

Arthroscopic resection of symptomatic unfused tibial tubercle ossicles causing chronic anterior knee pain due to recalcitrant Osgood-Schlatter disease has been shown to be a reproducible arthroscopic technique. Although a number of other surgical techniques have been described, including ossicle excision and tubercle-plasty, drilling of the tibial tubercle, bone peg insertion to induce fusion, open excision of loose fragments, direct bursoscopic ossicle resection, and closing-wedge tubercle osteotomy, with varied outcomes, this technique offers a minimally invasive approach with low risk. Complications including injury to the patellar tendon and scarring of the anterior fat pad have been previously reported, but this approach can be performed with minimal fat pad debridement and direct visualization of the patellar tendon during all resections. This article presents a technique for arthroscopic resection and debridement of unfused ossicles in patients with chronic anterior knee pain due to Osgood-Schlatter disease by use of minimally invasive arthroscopic techniques that are used in standard knee arthroscopy and should be familiar to most arthroscopists.

Narrative: Review of Anterior Knee Pain Differential Diagnosis (Other than Patellofemoral Pain).

This review presents a framework for constructing a differential diagnosis for chronic anterior knee pain associated with overuse other than patellofemoral pain. Traumatic, systemic, and pediatric injuries will not be covered. From superficial to deep, the anterior knee can be conceptually organized into four layers: (1) soft tissue, (2) extensor mechanism, (3) intracapsular/extrasynovial, and (4) intra-articular. From superficial to deep, diagnoses to consider include bursitis, patellar and quadriceps tendinosis, fat pad impingement, and plica syndromes.

Quadriceps Function In Chronic Anterior Knee Pain With Or Without A History Of Knee Surgery

It is unclear if a history of knee surgery additively affects quadriceps dysfunction in patients with chronic anterior knee pain (AKP). PURPOSE: To compare quadriceps function (strength, activation, and power) in chronic AKP patients with or without a history of knee surgery, to matched healthy controls. METHODS: Twenty-eight chronic AKP patients with (n=14; ACL reconstruction=5, meniscectomy=4, and both combined=5) or without (n=14) a history of knee surgery, and 20 matched (age, height, mass, BMI, thigh circumference, and physical activity) healthy controls participated in this cross-sectional study (average values of all three groups in the order of demographics listed above: 22 years, 173 cm, 76 kg, 25 kg/m2, 57 cm, 235 min/week). Perception and duration of pain, and functional outcomes were also matched between AKP patient groups (4.1/10 cm in visual analogue scale; 41 months; 54/80 score in Lower Extremity Functional Scale). For quadriceps strength, maximal voluntary isometric contraction (MVIC) was obtained. For quadriceps activation and power, central activation ratio (CAR) and rate of torque development during MVIC assessments were calculated. Parametric or non-parametric tests (depends on normal distribution) with calculations of effect sizes [ES] determined the group differences (p<0.05). RESULTS: As compared with the matched healthy controls, AKP patients with and without a history knee surgery showed a less quadriceps strength (3.1 vs. 2.2 [1.2] and 1.8 [2.3] N·m/kg, p<0.001) and power (10.1 vs. 7.8 [1.0] and 7.2 [1.1] N·m/kg/s, p<0.03). There were no differences between AKP patient groups in quadriceps strength (p=0.15) and power (p=0.79). A less quadriceps activation was observed in AKP patients without a surgery (0.75 in CAR), as compared with the knee surgery group (0.90 [1.7], p=0.002) and healthy controls (0.96 [3.0], p<0.0001). CONCLUSION: Both chronic AKP patient groups showed a similar amount of strength deficit that an experience of knee surgery does not appear to result in a summative effect. Central activation closed to normal (0.90 in CAR) in chronic AKP patients with a past surgical history may suggest that peripherally mediated inhibition plays a bigger role in their quadriceps weakness. Supported by the National Research Foundation of Korea (NRF-2017S1A8022854).

Effect of ultrasound-guided percutaneous neuromodulation applied to the femoral nerve on pain and range of motion in patients with anterior knee pain: A case study

Abstract Introduction Anterior knee pain (AKP) is one of the most frequent reasons for physical therapy consultations, remaining a difficult treatment challenge for professionals. The aim of this study was to evaluate the effects of an intervention using ultrasound-guided percutaneous neuromodulation (US-guided PNM) applied to the femoral nerve on pain and knee flexion range of motion (ROM), in patients with unilateral chronic anterior knee pain. Methods Eight patients received a single intervention of NMP-e on the femoral nerve of the symptomatic knee. The level of pain and ROM were measured before, immediately after and 24 hours after the intervention. Results A decrease in pain and an increase of ROM were observed after the intervention and at 24 hours. For pain values, a medium effect size was observed (ES = 0.63 ± 0.43) after the intervention, and a large effect size (ES = 1.73 ± 0.44) was found at 24h. Concerning ROM, the effect size was large at both moments (ES = − 1.30 ± 1.14; −1.76 ± 0.80, respectively). Conclusion A single intervention of US-guided PNM on the femoral nerve produces a decrease of pain and increases the ROM, which is greater 24h after the stimulation. Level of Evidence Level II-3.

Chronic Anterior Knee Pain in a Wrestling Athlete from a Neuroma of the Infrapatellar Branch of the Saphenous Nerve

Chronic Anterior Knee Pain in a Wrestling Athlete from a Neuroma of the Infrapatellar Branch of the Saphenous Nerve

Arab Knee: Management and Prevention-A Case Report

Radiographic osteoarthritis of the knee is very common in Saudi patients, especially in the patellofemoral compartment.&#x0D; Some studies have considered repetitive daily prayer activities as a factor of causation. However prevention and management recommendations appear to be non-existent in the literature. This report describes the case of chronic bilateral anterior knee pain in a devout adult male, which was dramatically alleviated by simply using a padded cushion under the prayer rug. Simple strategies of temporarily modifying prayer posture, insuring good prayer form, and adequate knee padding, may offer promise as low tech and economical solution for the management of anterior knee pain in this cultural group.

Physical examination of the patellofemoral joint

Patients with a patellofemoral pain are either in an acute state after a patellofemoral dislocation or are suffering from a chronic anterior knee pain (AKP), whereas AKP might be accompanied by patellar instability without dislocation. Whereas the acute state after a dislocation is mostly clear and its examination limited, the examination of a AKP is much more complex. A profound knowledge of the anatomy, the painful structures and patellofemoral biomechanics is essential in order to find the underlying pathology within the heterogeneous and diverse etiologies. Furthermore, a meticulous and precise examination is key to find the adequate treatment for AKP.

Physical examination of the patellofemoral joint

Patients with a patellofemoral pain are either in an acute state after a patellofemoral dislocation or are suffering from a chronic anterior knee pain (AKP), whereas AKP might be accompanied by patellar instability without dislocation. Whereas the acute state after a dislocation is mostly clear and its examination limited, the examination of a AKP is much more complex. A profound knowledge of the anatomy, the painful structures and patellofemoral biomechanics is essential in order to find the underlying pathology within the heterogeneous and diverse etiologies. Furthermore, a meticulous and precise examination is key to find the adequate treatment for AKP.

Application of ultrasound-guided percutaneus neuromodulation (PNM) in women with anterior knee pain

Abstract Background Anterior knee pain (AKP) is one of the most common pathologies of the lower limb, with an incidence that is 2.2% greater in women than in men. Electric currents have been used as an effective treatment for pain in many pathologies, however, the percutaneous application of the same has represented a particularly great advancement. In the field of physical therapy, ultrasound-guided percutaneous neuromodulation (US-guided PNM), is a technique that is being developed with promising results, however there is still a scarcity of studies concerning this technique. Aim To evaluate the improvement in chronic anterior knee pain symptoms after the application of US-guided PNM on the femoral nerve of the affected side or the healthy side, in a population of women. Material and Methods The sample comprised 15 women with chronic unilateral AKP, who were randomly divided into two groups: experimental group 1 (n = 8), who received US-guided PNM upon the femoral nerve, on the leg of the affected side, and an experimental group 2 (n = 7), who received US-guided PNM on the femoral nerve of the non-affected side. The intervention was performed using a needle measuring 0.3 × 40mm on the motor fibers of the femoral nerve under ultrasound guidance and using a monopolar electrode, with a frequency of 10 Hz and a phase duration of 250 microseconds, during 1.5 minutes. We registered active ROM in both knees, pain according to the Visual Analog Scale (VAS) and functionality using the VISA-P questionnaire and the Kujala scale. All variables were evaluated pre-intervention, post-intervention and after 24 hours. Results No statistically significant differences were found in both groups between the pre and post intervention measurements. However, statistically significant changes were found in both groups between the pre and post intervention at 24 hours, regarding increased ROM and functionality and a decrease in pain (p &lt; 0.05). Nonetheless, the between-group comparison did not obtain a significant difference in any of the variables studied (p &gt; 0.05). The measurement of the effect size obtained a large clinical effect between both groups and between the pre-intervention measurement and the assessment at 24 hours. Conclusion Treatment of chronic AKP in women, using US-guided PNM, leads to an improvement of symptoms and functionality, 24 hours after application of the same, regardless of whether it is applied on the femoral nerve of the affected leg or on that of the healthy leg.

An infrapatellar nerve block reduces knee pain in patients with chronic anterior knee pain after tibial nailing: a randomized, placebo-controlled trial in 34 patients

Background and purpose — Anterior knee pain is common after tibial nailing. Its origin is poorly understood. Injury of the infrapatellar nerve is a possible cause. In this randomized controlled trial we compared changes in knee pain after an infrapatellar nerve block with lidocaine or placebo in patients with persistent knee pain after tibial nailing.Patients and methods — Patients with chronic knee pain after tibial nailing were randomized to an infrapatellar nerve block with 5 ml 2% lidocaine or placebo (sodium chloride 0.9%), after which they performed 8 daily activities. Before and after these activities, pain was recorded using a numeric rating scale (NRS; 0–10). Primary endpoint was the change in pain during kneeling after the infrapatellar nerve block. Secondary outcomes were changes in pain after the nerve block during the other activities.Results — 34 patients (age 18–62 years) were equally randomized. A significant reduction of the NRS for kneeling pain with an infrapatellar nerve block with lidocaine was found compared with placebo (–4.5 [range –10 to –1] versus –1 [–9 to 2]; p = 0.002). There were no differences between the treatments for the NRS values for pain during other activities.Interpretation — Compared with placebo, an infrapatellar nerve block with lidocaine was more effective in reducing pain during kneeling in patients with chronic knee pain after tibial nailing. Our findings support the contention that kneeling pain after tibial nailing is a peripheral nerve-related problem.

Congenital internal rotation deformity of the distal femur presenting as patellofemoral instability and pain

ObjectivesFemoral antetorsion, defined as the angle of rotation of the femoral head and neck axis in relation to the transcondylar axis of the distal femur, is a cause for patellofemoral instability and anterior knee pain. Most clinical reports do not distinguish between antetorsion of the femur distal to the isthmus and anteversion of the proximal femur, which is another cause of femoral internal rotational deformity.MethodsThis retrospective observational case series evaluated four cases in three female patients who underwent evaluation of surgical intervention for chronic anterior knee pain since childhood. Physical examination and radiographic images supported the diagnosis of internal rotation deformity at the distal femora in all four cases. Distal femoral derotational osteotomy of 45°, 60° and 30° were performed, respectively. Kujala scoring system for patellofemoral pathology was used to assess the change in knee symptoms before and after the osteotomies.ResultsThis study demonstrated successful treatment of the resultant knee symptoms from femoral antetorsion with distal femur derotational osteotomy in all three patients.ConclusionsPatellofemoral syndrome is multifactorial, and the true anatomic reason for each patient’s individual pathology must be determined before surgery proceeds.Level of evidenceLevel V.

Lateral Patellofemoral Ligament Reconstruction With a Gracilis Allograft

Isolated medial patellar subluxation (MPS), in the absence of a previous lateral retinacular release, is a poorly recognized clinical condition characterized by chronic anterior knee pain that is exacerbated with knee flexion. This type of patellar instability is often overlooked, and a high index of suspicion is needed for appropriate diagnosis and treatment. The purpose of this Technical Note is to describe a surgical technique to reconstruct the lateral patellofemoral ligament with an allograft gracilis tendon. By restoring stability to the lateral side of the patella, this minimally invasive technique successfully treats cases of isolated MPS.

Evaluation of chronic anterior knee pain following interlocking nailing of diaphyseal fractures of tibia

Background: Chronic Anterior Knee pain is the most common post-operative complication following Intramedullary interlocking nailing of Tibial shaft fractures. Its incidence has been reported to range between 10 % to 86% but no definite cause can be attributed. This study was conducted to analyse the prevalence & severity of anterior knee pain in post tibial nailing patients with relation to nail protrusion, approach and proximal screw size. Methods and Material: 92 consecutive patients with an isolated tibia shaft fracture; treated with reamed IMIL nailing from 2014 to 2016 were included in the study. Chronic Anterior knee pain was assessed as per VAS. Besides X-ray, Ultrasound evaluation of patellar tendon morphology and nail protrusion was done. Statistical analysis used: student t test. Chi square test. Results: In the symptomatic group (28), 25patients (89%) had nail protrusion and only 3 patients (11%) did not have nail protrusion beyond proximal tibia cortical bone. In asymptomatic group, 20(33%) patients had nail protrusion and 40(67%) patients did not have nail protrusion. This difference was statistically significant with P value 0.00. In symptomatic group, 11(39%) patients had larger screws and 17(61%) patients had normal length screws. In asymptomatic group, 41(68%) patients had normal length and 19(32%) had large screw. P value came out to be 0.48. Conclusions: Anterior knee pain may be related to protrusion of nail beyond proximal tibial cortical bone [p value 0.01], and larger proximal screw length [p value 0.08].